Insomnia in women common, increases with age

HONOLULU — Established and evolving treatments are available to help women with insomnia, the prevalence, symptoms and outcomes of which may vary and intensify with age, according to a speaker at the CHEST Annual Meeting.

By definition, insomnia not only involves an inability to sleep at night, but it also impacts those affected during the daytime with fatigue, decreased mood or irritability, general malaise or cognitive impairment, Janet N. Myers, MD, FCCP, FAASM, medical director of Kaiser Permanente Sleep Center of Moanalua Medical Center and associate professor of clinical medicine at John A. Burns School of Medicine, said during her presentation.

It can also be chronic, meaning signs and symptoms are present at least 3 days a week for 3 or more months. Or, if those terms aren’t met, then it is considered to be short-term insomnia disorder.

“It used to be thought that insomnia was a byproduct of some other process that was going on, but now it’s considered its own comorbidity and deserves its own attention and treatment,” Myers said.

With chronic and short-term insomnia each affecting 10% of the population, that equates to 33 million affected individuals in the U.S., she added.

“These are patients that we’re not always picking up, so we should be asking about it,” she said.

Insomnia from pre- to post-menopausal

Among women, the prevalence of insomnia can range from 16% during pre-menopause to 60% during post-menopause, Myers said.

Women experiencing insomnia may have somatic complaints, such as pain or weakness, she added.

“But there really is no clear endotype for us to hang our hat on,” she said,” and there are no objective markers other than us just asking whether they have insomnia.”

Hormones are an obvious cause of these fluctuations in prevalence over time, Myers said. These can include postpartum physiologic and psychologic changes, as well as vasomotor symptoms that are associated with menopause, such as hot flashes.

During pregnancy, up to 80% of women may be affected by insomnia, especially during the third trimester, causing daytime fatigue and mood changes which can, in turn, negatively impact partner relationships and newborn bonding.

“Chronic sleep loss can be associated with numerous outcomes, but particularly adverse fetal outcomes and postpartum anxiety and depression,” Myers said. “It’s important to screen and treat insomnia so you can prevent these things down the road.”

Still, older women appear to be more affected by insomnia.

Data from the Study of Women’s Health Across the Nation showed 31% to 42% of women had insomnia symptoms, with the odds increasing for women in late-stage menopause vs. earlier-stage menopause (OR = 1.3; 95% CI, 1.2-1.5).

“As women age, they may be the most vulnerable group because they have prolonged sleep onset and lower melatonin secretion over time,” Myers said.

Treatment

Given that insomnia can impact so many areas of a woman’s life, a treatment strategy is imperative, Myers said.

It is important to recommend strategies for good sleep hygiene — such as going to bed at the same time every night and avoiding electronics before bed — but some individuals also prefer to take treatment, Myers said. Data also suggest that women are more likely than men to take medicine to help with sleep, she added.

However, for insomnia during pregnancy, other approaches such as cognitive behavioral therapy or massage are preferred.

“But it’s a hard thing to suffer through, so a lot of women do want medication,” Myers said, adding that melatonin is used by 4% of pregnant women.

Trazodone and diphenhydramine also have been studied in this population and shown to significantly improve sleep and reduce postpartum depression compared with placebo, but more data are needed on outcomes for the baby and on lactation, according to Myers.

“I would think about those other factors and not just getting your patient to fall asleep,” she said.

For postpartum anxiety and insomnia, zuranolone (Zurzuvae; Biogen, Sage Therapuetics) recently became the first FDA-approved oral treatment for postpartum depression, she added.

During menopause, cognitive behavior therapy, hormone replacement therapy, antidepressants and long-acting melatonin are all options, Myers said.

But, when it comes to longer-term treatments for these patients, Myers recommended referencing a treatment algorithm available from Proserpio and colleagues, in addition to discussing dietary interventions with a low glycemic index.

Increasingly, patients also may be asking about the use of cannabis gummies with melatonin to help treat insomnia, Myers said.

“It’s out there, and your patients are taking this medication, so you ought to know about it and have something to be able to tell them,” she said. “Even though these products are out there, they may work in the short term but there are not data that say that this is something you should be using long term.

“So, try to be accepting, but try to encourage patients not to use it continually because when you do, and you try to come out of it, you can have really bad reactions,” she added.

References:

• Ciano C, et al. J Obstet Gynecol Neonatal Nurs. 2017;doi:10.1016/j.jogn.2017.07.011.
• Proserpio P, et al. Climacteric. 2020;doi:10.1080/13697137.2020.1799973.